Quiz Feedback: Medication errors/Cough and cold in children

1. Which of the following details are recommended to be included on a prescription written for a
child?

Your peers

Answer

Current weight

90%

Dose expressed as mg/kg

86%

Standardised abbreviations

18%

Indication

88%

Specific instructions

98%

Question 1 comments

Most people correctly selected the details that are recommended to be included on a prescription. This message seems
to be well understood.
To help minimise the occurrence of medication errors, prescribers are encouraged to include the following
details (where appropriate) when prescribing, especially for children:

Indication for medicine e.g. on prescriptions for paracetamol state “only for use in pain or fever”

Specific instructions (avoid vague instructions such as “take as directed” or “when required”)

Abbreviations and symbols have historically and commonly been used in prescribing but this practice is no longer recommended.
This may account for the 18% of respondents who incorrectly indicated that abbreviations should be included on a prescription.
Using abbreviations and symbols can be a source of confusion and misinterpretation e.g. HCT is used for both hydrocortisone
and hydrochlorothiazide, O.D can be mistaken for Q.I.D or BD.

2. A 9-year-old child who weighs 27 kg is prescribed ibuprofen for pain and fever related to the
common cold. Which one of the following doses is the most appropriate?

Your peers

Answer

Ibuprofen 100 mg/5 mL, 50 mg (2.5 mL), three to four times per day

1%

Ibuprofen 100 mg/5 mL, 100 mg (5 mL), three to four times per day

66%

Ibuprofen 100 mg/5 mL, 200 mg (10 mL), three to four times per day

34%

Question 2 comments

Ibuprofen is not considered a first line analgesic/antipyretic medicine because of its association with increased
risk of GI bleeding in addition to renal toxicity and aspirin-like sensitivity reactions. The recommendations when prescribing
ibuprofen for children are:

For infants and children the usual oral dose is 20 mg/kg/day, in divided doses

If the child is over 7 kg and has a severe condition, this can be up to 30 mg/kg/day

In children weighing less than 30 kg, the total daily dose should not exceed 500 mg

Always use the lowest effective dose, for the shortest possible duration, and preferably administer after food

A reasonable oral dose for a nine-year-old child would usually be 200 mg, three to four times per day (as selected
by 34% of respondents). However in the example above, the child weighs less than 30kg, so the total daily dose should
not exceed 500 mg. So for this child, the most appropriate of the three dose options would be 100 mg ibuprofen, three
to four times daily.

3. A 12-year-old child who weighs 45 kg is prescribed paracetamol for pain and fever related to
the common cold. Which one of the following doses is the most appropriate?

Your peers

Answer

Paracetamol 120 mg/5 mL, 120 – 250 mg (5 – 10 mL), every four to six hours, maximum
four doses per day

0%

Paracetamol 250 mg/5 mL, 250 – 500 mg (5 – 10 mL), every four to six hours, maximum
four doses per day

57%

Paracetamol 250 mg/5 mL, 500 – 1000 mg (10 – 20 mL), every four to six hours, maximum
four doses per day

43%

Question 3 comments

Paracetamol is the preferred first-line analgesic for children for fever and mild to moderate pain as it has few adverse
effects when dosed correctly. However, serious and sometimes even fatal liver toxicity can occur with acute and chronic
overdose, so for this reason it is prudent to take time to calculate or look up safe dosing regimens when prescribing
paracetamol for children.

The weight-based dose for paracetamol in children is generally 10–15 mg/kg, every four to six hours (maximum
of four doses in 24 hours). The BNF for children (BNFc) gives age-based dose regimens and recommends a paracetamol dose
for children 6–12 years of 250–500 mg every 4–6 hours (maximum 4 doses/24 hours).

In the example above, a conservative approach would be to follow BNFc recommendations and prescribe 250- 500 mg paracetamol,
every four to six hours (as selected by 57% of respondents). However as the child weighs over 40 kg, it would be acceptable
to prescribe a regular adult dose, therefore 500 – 1000 mg paracetamol, every four to six hours is the most appropriate
dose in this situation (as selected by 43% of respondents).

4. A GP writes the following prescription for paracetamol for an 8-year-old child who weighs 25
kg: “Paracare 250, 5.0 mL, prn”. Which of the following are errors with this prescription?

Your peers

Answer

Wrong dose given based on age

28%

Trailing zero used

76%

Brand name used rather than generic name

75%

Clear instructions for use not given

99%

Maximum amount of doses per day not indicated

97%

Question 4 comments

In the example above the child weighs 25 kg, so using the 10-15 mg/kg dosing regimen, this would work out as 250-375
mg, every four to six hours. The BNFc recommends a paracetamol dose for children aged six to 12 years of 250-500 mg,
every four to six hours. Therefore, if it is inferred that the prescriber intended the dose to be 250 mg paracetamol,
every four to six hours, then this is the correct dose based on the child’s age and weight (although 28% of respondents
disagreed with this).

The errors with the prescription are; trailing zero used (which could be misinterpreted as 50 mL instead of 5 mL),
brand name used (Paracare) instead of generic name (paracetamol), clear instructions for use and maximum daily dose
not given (all potentially leading to misinterpretation and medication error).

Ideally the prescription would be better written as: Paracetamol 250 mg/5mL, 5 mL to be given, every four hours, as
required for pain or fever, maximum of four doses per day.

5. Which of the following are considered as “red flags” in children with cough:

Your peers

Answer

Neonatal onset of cough

98%

A history of choking

98%

A wet sounding cough lasting more than four weeks

90%

Associated symptoms of nasal congestion, sore throat and fever

1%

Continued parental concern despite reassurance

94%

Question 5 comments

Although the majority of children with an acute cough presenting to general practice are likely to have a viral upper
respiratory tract infection (URTI), the possibility of a more serious problem should be considered. Other serious causes
of acute cough e.g. pneumonia, pertussis, foreign body inhalation should be considered and excluded if possible, especially
in coughs that persists.

A cough associated with a very sudden onset or a history of choking may suggest inhalation of a foreign body, particularly
in younger children.

“Parents know their child best”, so any reasonable concern that persists, despite reassurance, should
be seriously considered and other causes for cough investigated.

These concepts seem well understood by respondents.

6.
Which of the following characteristics are typical of habit cough syndrome?

Your peers

Answer

Often starts with an upper respiratory tract infection

92%

Usually causes the parents more stress than the child

90%

Increases during enjoyable activities

3%

Occurs particularly in the morning

6%

May be associated with a history of psychological problems

94%

Question 6 comments

Habit (psychogenic) cough is estimated to be the cause of persistent cough in children in 3–10% of cases. Diagnosis
should only be made after other causes have been excluded, such as a transient or chronic tic disorder or Tourette’s
syndrome.

Features of habit cough include:

A dry harsh cough, repetitive and often reproducible on request

Often begins with an URTI, which then persists

Cough can occur at any time, can decrease during enjoyable activities, disappear at night, and can be disruptive
to others while the child seems oblivious to it

The child may have a history of psychosocial problems such as abuse, anxiety, school phobia or depression

These concepts seem well understood by respondents.

7.
Which of the following statements about investigations for cough are true?

Your peers

Answer

Investigations are not required for a child with an acute cough and a diagnosis of viral URTI

90%

Spirometry is indicated for chronic, dry cough

85%

A diagnosis of asthma can be ruled out if spirometry is normal

1%

A chest x-ray will confirm if a foreign body has been inhaled

10%

Sputum should always be collected in cases of a wet, chronic cough

29%

Question 7 comments

In general investigations are not required for children with acute cough who are likely to have a diagnosis of a viral
URTI, which will be the majority of cases presenting to general practice.

Spirometry can be useful for investigating a chronic dry cough in a child who is old enough to master the technique
(usually school age). However normal results do not exclude a diagnosis of asthma.

A chest x-ray may provide useful information in a child with chronic cough, abnormal chest signs or history of aspiration
e.g. possible foreign body inhalation (although a normal chest x-ray does not exclude this possibility).

Sputum collection is often not useful as most young children swallow their sputum and are unable to produce a sample
of sufficient quality for analysis. If a sample can reliably be collected, sputum analysis may be useful for older children
with a chronic wet cough. This point appears to have caused some confusion, with 29% of respondents.

8.
Which of the following statements, when giving advice to parents managing a child with fever at home,
are true?

Your peers

Answer

Use paracetamol if the child is distressed due to the fever

98%

Routinely use ibuprofen together with paracetamol for more effective management of fever

1%

The “tepid sponging” method is recommended to reduce fever

17%

Keep up regular fluids

99%

Seek further help if the parent is more worried than when they previously sought advice

97%

Question 8 comments

Paracetamol can be considered first-line for the treatment of pain and fever. Ibuprofen is also effective for pain
and fever, but is considered, especially in children, to be a second-line alternative to paracetamol. Parents/carers
can sometimes perceive that paracetamol and ibuprofen if effective separately will be even more effective when used
together. Advice to parents should be:

To use paracetamol as first-line and to only add in ibuprofen to the regimen if there is no response to paracetamol
and to NOT routinely use paracetamol and ibuprofen together

Not to use paracetamol for the specific purpose of preventing febrile convulsion

Other advice for managing fever at home includes not under-dressing or over-wrapping the child. Although selected
by 17% of respondents, “tepid sponging” is not an effective method for reducing fever and causes distress
to most children, therefore it is no longer recommended (See Correspondence, “Tepid sponging”, BPJ 30, August
2010 for more information). Keeping up regular fluids and checking for deterioration in the child’s overall condition
is essential for parents/carers.

9.
Which of the following statements about cough and cold preparations are true?

Your peers

Answer

Antitussives are no more effective than placebo in alleviating symptoms

91%

Beta-2 agonists, such as salbutamol, reliably reduce the severity and duration of acute cough

2%

Most cough and cold preparations contain medicines that are not recommended in children aged less
than six years

96%

Cough and cold preparations that are effective in adults will also be effective in children

Question 9 comments

A 2008 Cochrane review found that antitussives, antihistamines, antihistamine/decongestant combinations and antitussive/bronchodilator
combinations were no more effective than placebo in alleviating symptoms of cough and cold. Medsafe recommends that
cough and cold preparations containing medicines such as antihistamines, antitussives, expectorants and decongestants
should not be used in children aged less than six years.

Beta-2 antagonists e.g. salbutamol, have not been shown to reduce the incidence or severity of cough in children with
acute cough, with no airflow obstruction.

Infection with the common cold can affect children and adults differently, therefore products which may be effective
for adults do not necessarily work in the same way for children. It is acknowledged that the placebo effect may play
a significant role in the anecdotal success and popularity of using cough and cold preparations.

Many cough and cold preparations contain either a CNS depressant e.g. promethazine or a CNS stimulant e.g. phenylephrine.
This can lead to adverse CNS effects, even following recommended doses, such as sedation, psychomotor impairment, insomnia,
tremor and hyperexcitability.

These concepts seem well understood by respondents.

10.
Which of the following statements, when giving advice to parents managing a child with the common
cold, are true?

Your peers

Answer

Saline drops can help relieve nasal congestion

98%

Honey may be trialled in children as young as three months

8%

There is evidence that echinacea prevents occurrences of the common cold in children

3%

Paracetamol is recommended first-line for the treatment of pain and fever associated with the common
cold

98%

Keeping the house warm, dry and smoke free can reduce the incidence or severity of the common cold

95%

Question 10 comments

Although widely used, most cough and cold preparations are not effective at reducing symptoms related to cough and
cold in children. Paracetamol is recommended as the first-line treatment for pain and fever associated with cough and
cold. Saline drops or spray may be used as a nasal decongestant, particularly in younger children and infants. Although
there is a lack of clinical evidence of effectiveness, honey is regarded as a safe treatment to trial for a child, aged
over one year with cough and cold. Honey should not be used in children younger than one year, due to the very rare
association of honey with infant botulism. There is no evidence that echinacea prevents occurrences of cold.

One of the most important things that parents can do for their child with cough and cold, is to provide a “healthy
home” environment i.e. a warm, dry and smoke-free house, and provide general care such as encouraging rest, adequate
fluid intake and keeping the child clothed warmly.